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This assignment will be analysing the impact of homelessness on the health of individuals and focusing on the effect homelessness has on a persons mental health and evaluating the response of health providers.

The legal definition of homelessness states that an individual as being homeless if they do not have a legal right to occupy accommodation, or if their accommodation is unsuitable to live in. (Homelessness Act 2002)

Homelessness is a major social issue especially in urban areas; in 2008 3500 people slept rough in London alone (Broadway 2009). Homelessness is often referred to as sleeping on the streets; this is a common misconception with homelessness existing in many different forms. In reality sleeping on the streets is the most extreme form of homelessness. (Initiatives to tackle homelessness and rough sleeping in London 2008)

Homeless people could either be families or single people who do not sleep on the streets but live in alternative accommodation, this is supported by the Government which stated in 2003: “the vast majority of homeless people are actually families or single people who are not literally sleeping on the streets but living with relatives and friends or in temporary accommodation (ODPM 2003). The majority of homeless people live in temporary accommodation; these include bed and breakfasts, hotels, shelters, refuges or hostels. These temporary forms of accommodation tend to be poor quality and detrimental to their health and well-being. The results of not having permanent accommodation have a direct link to high stress levels and practical difficulties.

Local authorities have a legal duty to provide assistance and advice to people who are legally defined as homeless, or someone who is threatened with homelessness. However, due to the criteria of need not everyone within the legal definition of homelessness necessarily qualifies for accommodation. (Pereira test)

A majority of people view homelessness as the result of individuals personal failings in life, and believe that a person chooses to be homeless. Research by the Scottish government found that 48% of the UK public believed that homeless people could find somewhere to live if they tried, and 35% believed that people became homeless, purely on the basis to receive a council house. (Ormston 2006)

However the causes of homelessness are a complex interplay between a persons individual circumstances and difficult “structural” factors, which are outside their control. These problems can build over years, until a point where everything has reached crisis, this is when an individual becomes homeless.

Fitzpatrick (2005) explored the positivist and interpretivist schools of thought. These two models are based on different theories about the nature of reality. Positivists believe that knowledge can only be established on what can be experienced or observed. Positivist looks at statistically significant variables for example the lack of social housing and an individuals family problem can lead to someone becoming homeless. However, this cannot include the population as a whole, not all people with family problems in areas where there is a lack of social housing becomes homeless. These people are at an increased risk of becoming homeless, however it does not explain the causes of homelessness. Interpretivism is a term that includes various paradigms, all related with meanings and experiences of human beings.

Fitzpatrick (2005) concluded critical realism could explain the reasons why people become homeless. Realists take in a number of factors which could result in someone becoming homeless, for example economic structures, depending on welfare policies and social class can make someone more venerable to homelessness. Realists also consider the supply of affordable housing as an attribute to homelessness.

Giddens developed the Structuration Theory which stated that power exists at different points within society for example local authorities, councils and the government. However Giddens states that an individual can have an impact and change things from happening. For example if a childs had substance dependency, the child is more likely to also have substance dependency; this is their predictable fate. Giddens however argues that an individual can have an impact of what happens to them. Similar to the interpretivist approach, Giddens acknowledges that social life is produced and reproduced through action. (Giddens)

Post modernists and post structualists argue that there is no one reason for someone becoming homeless. People can become homeless from a range of complex and overlapping reasons; for example, an individual may have alcohol dependencies, which could lead to the end of a relationship, thus being thrown out of the marital home. Solving homelessness is more complex than simply putting a roof over an individual/familys head; work needs to be carried out to solve the underlying issues that resulted in the cause of homelessness in the first instance. These issues may include individual factors, which can consist of alcohol or drug misuse, a lack of social support from friends or family, poor physical or mental health, relationship breakdown through divorce, the demise of a relationship and debts- particularly mortgage or rent arrears. Family background may also be a contributing factor to homelessness; this may include family breakdowns and disputes, physical and sexual abuse in childhood, having parents with alcohol or drug dependencies, or a family history of homelessness. Research by Ravenhill 2000 examined the routes into homelessness found that family conflict was the most common starting point for homelessness.

Having an institutional background may also contribute to an individual becoming homeless, these include people who have been in care, in prison or in the armed forces. This statement is backed up by a report commissioned by Shelter 2007 found that 25% of homeless people has spent time in prison.

Structural causes of homelessness are social and economic in nature; these are often outside the control of the family or individual concerned.

This may include the lack of affordable housing; in England 4.5 million people are on the social housing waiting list (CLG 2009) This number is predicted to rise some 2 million households by 2010 (LGA 2008). As the demand for social housing rises, the supply has decreased by 32%, in 1981 there were 5.5 million, in 2007 there were 3.7 million (CLG 2008).

Poverty can also be associated with a structural cause of homelessness, a lack of monetary resources make people more vulnerable to homelessness as they do not have financial stability, for example, unemployment. Poverty is on the increase in the UK in 2007/ 2008 almost 13.5 million people were living in poverty. The housing benefit system can also prevent people recovering from poverty. This system creates barriers for those trying to work (unemployment trap) and people in low paying jobs trying to increae their income (poverty trap). Housing benefit can also block claimants effort to gain new qualifications, as anyone over the age of 18 is not eligible for Housing Benefit if they are studying more than 16 hours per week. These above factors are out of the individuals hands, as they require policy solutions, such as changes in the housing benefit system, and the building of more affordable housing in all local authorities.

Applicants for homelessness support from local authorities identified that the three main reasons for having lost their last settled home were; family or friends were unwilling or unable to accommodate them, the loss of assured short hold tenancy and relationship breakdown (Statutory Homelessness Statistics 2008). However these reasons are only factors, which trigger people into seeking assistance, and are not the fundamental reasons that build up in the first place. For many people there is no single event that results in sudden homelessness, however homelessness is due to a number of problems that have built up over time. Homelessness can reoccur in the future as a result of underlying problems and issues remaining unresolved.

A study commissioned by Shelter 2007 found that the most frequent reason given for living on the street were, relationship breakdown: 41 per cent, being asked to leave the family home: 28 per cent, drug and alcohol problems: 31 per cent and 28 per cent respectively, leaving prison: 25 per cent, mental health problems: 19 per cent, other: for example, eviction, problems with benefits payments. Interviewees identified two or three factors contributing to their homelessness, which reveal that causes of homelessness cannot be because of one single factor.

Crane (1999) argued that unemployment; availability of affordable housing and poverty had little effect on someone becoming homeless. Crane found in her respondents that personal inadequacies such as mental health, emotional distress and coping abilities were more significant as causes of homelessness.

The experience of homelessness can have a serious detrimental effect on a persons physical and mental well-being. This is especially true in the case of rough sleepers, who have on average life expectancy of 42 years, compared to the national UK average of 74 for men and 79 for women (Grenier 1996) Poor physical or mental health as well as alcohol or drug dependency are health problems for the entire homeless population, whether they are sleeping on the street, in hostels or in temporary accommodation.

Mental ill health, physical disabilities or dependency issues can also trigger or be a part of a chain event that lead to someone becoming homeless. Isolation created by being homeless often means that people find it difficult to access support with services not being in a position to respond to the needs of homeless people.

Poor physical health and homelessness often go hand in hand, sleeping on the streets, in squats or in overcrowded accommodation can have a damaging effect on a persons physical well being. In 2006, the National Coalition for the Homeless found that 142 violent acts by non-homeless people against homeless people, 20 of which were fatal.

A recent survey of homeless people living in hostels, found that two thirds were suffering from physical health problems which included trench foot, frostbite, bronchitis, pneumonia, wound infections, cardiovascular conditions and liver damage. (St Mungo’s 2005) Homeless people also lack adequate access to healthcare services. St Mungos research also found that one third of hostel residents who required treatment did not receive any.

Research has found that homeless people are 40% times more likely not to be registered with a GP than the general public; research has also found that 55% of homeless people had no contact with a GP in the previous year. (Fountain 2002)

Mental ill health is both a cause and also a consequence of homelessness. It is commonly known that there are higher rates of mental health problems in the homeless population. Mental health issues can be caused by the stress associated with being homeless, research by Homeless Link 2009 found that 32% of clients of homelessness services in England have mental health and 14% have personality disorder. Broadway 2009 found that rough sleepers are 35 times more likely to commit suicide than the general population. A report for (Rees 2009) found that the homeless population were twice the levels of common mental health problems, and research found that Psychosis is 4 to 15 times more present in homeless population.

Breakdown of a relationship may lead to depression or mental health problems; alcohol may then be used as a coping mechanism to numb the pain. Over two thirds of homeless people reported drug or alcohol use as a reason for first becoming homeless (Crisis 2002). Kemp 2006 also found that those who use drugs are seven times more likely to become homeless than the general population. Homelessness is associated with high levels of stress and mental illness and it is common for those who are traumatised by homeless to seek comfort in alcohol or drug abuse. However not every person who has alcohol or drug dependencies becomes homeless, likewise not every person who is homeless has drug or alcohol problems. However there is a high prevalence of alcohol and drug problems in the homeless population; Homeless Link (2009) found that 39% of clients of homeless services in England have problems with alcohol and 42% has drug problems. Mental health illness is also associated with substance misuse, this is called dual diagnosis. Services for this group are particularly poor, as dependency services have difficulties to cater for people with mental health issues, as do mental health services find it difficult to cater for people with substance misuse.

Alcohol dependency, mental ill health and drug dependency are the most common expressed health needs of people who are homeless. There are different types of services aimed at providing homeless people health care. However there are barriers preventing homeless people accessing these services. In order to address these barriers different types of frameworks have been established. The first being the mainstream general practice (intended for the general public) which adopts the extended role in primary care provision. “Specialised” general practice being the second framework to address barriers in accessing health care specifically for homeless people; this practice only registers homeless people. This type of practice is usually only found in large urban areas where homelessness is greater, this service is therefore unobtainable for homeless people in rural areas. The positive aspect of this framework is that in attempts to integrate homeless people into mainstream general health care, this statement being supported by Lester (2002). However, Wright 2002 argues that specialised general practice can provide a focussed and intensive level of care for homeless people, where integration in to mainstream primary care could be problematic. Wright therefore concluded that this type of framework is a useful tool to provide the initial treatment for homeless people and not the long-term treatment. In essence Specialised general practice offers flexible, high quality and individually tailored responses when treating homeless people with services being open access such as drop in centres.

Research by Hagan et al 2001 found a high prevalence of Hepatitis C in injectors who shared injecting equipment. Health promotion for drug dependant homeless people should therefore encourage drug users not to share injecting equipment. Within the UK this has been made possible by setting up a legal framework for distributing sterile injecting equipment Hagen et al 2001. This will make users more aware of the health risks of sharing injecting equipment, and giving homeless people access to health information, and making them aware of the risk factors of sharing needles, spoons and filters.

Readily available and accessible health care is required for effective health interventions for homeless people. This involves addressing the barriers in accessing health care and multiagency work in order for homeless people to access the full range of health and social care services.

Homeless people face many barriers when accessing health care services; these include the administration of the NHS, which requires a patient having a permanent address before being eligible. Pleace (2000) found that homeless people have often encountered negative attitude and refusal of service by some administrative staff. Due to low self-esteem many homeless people avoid attempting to access these services as they anticipate a hostile environment, which can lead to individual neglecting their health. Numerous homeless people are more concerned with obtaining food and shelter, prior to seeking health care requirements.

Evaluations on the services addressing dual-diagnosis, (mental health and substance use, being most frequent) are rare in the UK. Wright et al (2003) concluded that dual diagnosis services were not as competent as single diagnosis services. Health care services that specialise in dual diagnosis will often need specialised accommodation, offering long term sometimes on a permanent basis.

In order for Health care services to provide to the needs for homeless people, it needs to adopt a holistic approach, while ensuring user involvement in their care. Ensuring flexible opening times is also a factor which would help meet their need, many people sleeping rough sleep during the day, therefore providing services which are open during the evening would ensure access to homeless people. Many homeless people live in isolation and therefore depend of receiving information about available services through other people in the same situation; the information is therefore not widespread.

Homeless people with mental health problems often have difficulties accessing health care services for their needs, therefore resulting with a delay in receiving support or treatment and worsening their condition. It is essential to identify mental health problems and addressing them before a situation reaches crisis.

Difficulties in accessing services can be a result of relocating and being situated in different area code, as a result homeless people are therefore not registered with a GP and are reluctant attended different services as they anticipate hostility from staff.

In order to ensure that services are accessible to homeless people with mental health problems, services should ensure that mental health services are based within homeless agencies such as shelters and temporary accommodation. These agencies should be open access to ensure homeless people have access to the required resources. There should be dedicated specialist homelessness mental health practitioners visiting homelessness accommodation in order to identify and addressing mental health problems. There is also a requirement for support and training for frontline staff, so that they have the capability and knowledge to identify the symptoms of mental health problems. Frontline agencies in contact with homeless people play a key role in identifying possible mental health problems and then referring them to a specialised team. However, at present not all staff are trained to recognise individuals with mental health problems, for example, homeless people with a withdrawn behaviour can be overlooked, as they do not cause difficulties when staying in temporary accommodation.

Homeless people with mental health problems may need support from various different agencies, it is essential for these services to work together to ensure that the individual is receiving the care that they need, and is therefore important for different agencies to share information and conduct joint case conferences.

In order for local authorities to meet the mental health needs of homeless people, they must identify what their needs are, in order to identify any gaps in provision. In 2003 all local authorities were required to have a homelessness strategy in place, which should be based on the level and cause of homelessness in their specific area. Local authorities are required too keep strategies under review as homeless people needs vary, ensuring that these strategies are revised every five years. The Department for Communities and Local Government has issued a toolkit in order to assist different local authorities with their review, this emphasises the need to address health issues including mental health (DLG 2006) This is supported by the Homelessness Act (2002) which states that local authorities are obliged to carry out a homelessness review for their district; and formulate and publish a homelessness strategy based on the results of that review. (Homelessness Act 2002)

Scottish Government have set Health and Homeless Standards in 2005 which publish health and homelessness standards for NHS boards, its aim was to improve the health of homeless people and support NHS boards in the planning and provision of services for homeless people.

In conclusion, this assignment has shown that homelessness has a direct effect on an individuals health; health providers need better funding in order to provide efficient services for homeless people. However in order for local authorities to review their service in order to meet the needs of individuals would be difficult. Measuring how many homeless people exist is complex, many homeless people tend to avoid services, preferring isolation, services available will therefore not meet.

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